Innovative esophageal lengthening surgical technique in giant hiatal hernia repair

Introduction

Hiatal hernia is defined as herniation of the stomach through the esophageal hiatus into the thoracic cavity. Hiatal hernia is classified into four different types based on the location of the gastroesophageal junction in relation to the diaphragm and the content of the herniated organ. Type I is sliding hernia; type II which is rare is paraesophgeal hernia; type III is combination of both sliding and paraesophageal hernia; and type IV has herniation of additional organ such as colon (1). There is no uniform definition of giant hiatal hernia, but it typically describes herniation of at least 30% of the stomach above the diaphragm (2). Patients with symptomatic giant hiatal hernias are recommended to undergo surgical repair with fundoplication. There is no medical therapy that can bring the herniated stomach back into the abdomen. In patients with a giant hiatal hernia, surgeons can encounter a short esophagus during surgical repair. A short esophagus is defined as an intraoperative finding of less than 2 cm of intraabdominal esophageal length after reduction of the stomach, which results from longitudinal scarring due to gastroesophageal reflux disease (3,4). The short esophagus is a problem encountered approximately 10% of the time during hiatal hernia repair (4). Two traditional solutions to this problem are further dissection into the mediastinum or perform Collis gastroplasty (5). Here, we present a novel method of esophageal lengthening by circumferential resection of the fibrotic tissue on the esophagus above the gastroesophageal junction, which releases the esophagus and provides an adequate length below the diaphragm. In this report, we describe a step-by-step method of performing robot-assisted giant hiatal hernia repair with Toupet fundoplication. In these figures, we show the steps of hiatal hernia repair with Toupet fundoplication. In the video, we highlight the method of resecting fibrotic tissue around the esophagus to obtain an adequate intra-abdominal esophagus. I present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-41/rc).

Preoperative preparation and requirements

Patients with symptomatic reflux or early satiety refractory to medical therapy should undergo an esophagram (6). If the esophagram shows a giant hiatal hernia, the patient should be considered for robot-assisted giant hiatal hernia repair with Toupet fundoplication. Patients should be placed on enhanced recovery after surgery and medically optimized before surgery to achieve optimal surgical outcomes (7). The surgeon should have appropriate training in using the Da Vinci Xi robot during this operation. Typically, bedside assistance is required to help with changing the robotic instrument and placement and removal of sutures, Surgicel, felt, and Penrose drain. Surgery was performed in the operating room under general anesthesia. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for use of patient’s information and video for education purposes. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Port placement

We used Da Vinci Xi to perform robot-assisted hiatal hernia repair with Toupet fundoplication. After the patient underwent general anesthesia with single-lumen intubation, the patient was placed in the supine position, and the abdomen was prepped and draped in the usual standard fashion. A footboard was placed to prevent the patient from slipping on the bed. We placed four 8-mm robot ports (Figure 1) and a 5-mm port for the liver retractor. A liver retractor was placed and the left lobe of the liver was elevated to expose the hiatus. The patient was placed in the reverse Trendelenburg position at about 25-degree angle. We then dock the Da Vinci Xi (Intuitive Surgical, Sunnyvale, CA, USA) centered over the midline port and placed the cadiere grasper in ports #1 and #4, the camera in port #2, and the vessel sealer in port #3.

Figure 1 Robotic port placement (illustrated by Rachael Whitehead).

Mobilization of the hernia sac

The crucial part of the operation is separating the hernia sac layer from mediastinal structures. Determining the correct layer is key to this portion of the operation. The correct layer has an avascular plane between the hernia sac and mediastinal structures. The best area to locate this layer is in the middle of the attenuated phrenoesophageal ligament. The goal is to use the right cadiere grasper to pull the hernia sac into the abdomen, while the left cadiere provides counter tension on the diaphragm. This pulls the hernia sac away from the diaphragm and pericardium, and a vessel sealer is used to divide the hernia sac (Figure 2A). After the sac was divided, we continued separation of the sac from the mediastinal structure, moving toward the left crus. Once the left pleura was free from the hernia sac, we divided the sac with a vessel sealer, leaving approximately 1 cm of the hernia sac/peritoneum on the diaphragm and the left crus (Figure 2B). This layer prevents sutures from passing through the muscle during crus closure. Subsequently, the gastrohepatic ligament was divided. This provides a visualization of the right crus. The hernia sac was pulled to the left lower quadrant with the left cadiere. The right pleura was separated from the hernia sac and the sac was divided from the right crus (Figure 2C). This dissection is performed until the posterior hernia is separated from the aorta and communicates with the left side of the esophagus. Subsequently, we identified the inferior portion of the right crus and dissected the inferior portion of the left crus. The hernia sac was then separated from the left crus. A small patch of the hernia sac was still attached to the mid portion of the left crus, which was addressed after the division of the short gastric. At this point, the stomach was reduced to the abdomen (Figure 2D). We measured approximately 12 cm from the gastroesophageal junction, divided the short gastric artery, and entered the lesser sac (Figure 3A). The short gastric artery was divided up to the gastroesophageal junction. The fundus was pulled to the right lower quadrant, and the last portion of the hernia sac on the left crus was divided.

Figure 2 Hiatal hernia sac dissection (A-D) (illustrated by Rachael Whitehead).

Figure 3 Division of short gastric artery (A) and resection of fibrotic tissue around the esophagus (B) closure of the crus (C) and creation of Toupet fundoplication (D) (illustrated by Rachael Whitehead).

Resection of the hernia sac and fibrotic tissue

Once the hernia sac was separated from the pleura, pericardium, aorta, and mediastinal structures and completely divided from the left and right crus and diaphragm, we examined the length of the esophagus. Typically, there is a lot of tissue around the gastroesophageal junction, which makes the identification of the gastroesophageal junction difficult; however, overall, the esophagus appears to be above the diaphragm. The division of the hernia sac from the gastroesophageal junction and 3 cm of fibrotic tissue from the esophagus provides the length of the esophagus. There is an “accordion effect”, in which the hernia sac and fibrotic tissue keep the esophagus short in this area. The risk of resection of this tissue is injury to the anterior and posterior vagus nerves as well as branches or the main left gastric vessels. This method avoids injury to these critical structures (Video 1).

The hernial sac was pulled down to visualize the anterior vagus traveling down toward the lesser curve of the stomach. We divided the hernia sac approximately 1 cm from the patient’s left side of the anterior vagus nerve (Figure 3B). At the base, there were two separate layers. One layer of the sac is attached to the stomach along with vessels from the stomach, while the other layer is fibrotic tissue on top of the esophagus. The hernia sac is divided circumferentially from the stomach but stops prior to the posterior vagus nerve. Fibrotic tissue was bluntly separated from the esophagus. Dissection should be performed on the tissue, not on the esophagus. Approximately 3 cm of the tissue was mobilized on the left side of the vagus nerve and divided circumferentially until the posterior vagus nerve.

Next, we pulled the tissue on the right side of the vagus, overlying the esophagus, to the left lower quadrant. We grabbed the tissue above this point and bluntly dissected it off the esophagus. Approximately 3 cm of fibrotic tissue was separated and removed above the esophagus. We divided the tissue below the anterior vagus nerve to ensure complete dissection of the tissue on the patient’s right side. The hernia sac is brought under the esophagus and divided, ensuring preservation of the posterior vagus. Once this is completed, there is an adequate length (>2 cm) of the esophagus below the diaphragm.

Closure of the crus and Toupet fundoplication

The EndoFLIP was placed across the gastroesophageal junction and filled with 30 ml of fluid (8). The crus was closed with a 2-0 nonabsorbable braided suture (V-loc) with a pledget on the crus (Figure 3C). Ensure that the first bite with V-loc on the left crus is performed by lifting the left crus away from the aorta to avoid injury to the aorta. We checked the EndoFLIP values at the end of closure to ensure that the area was not too tight. We placed a marking suture approximately 6 cm from the gastroesophageal junction on the greater curvature side and 1 cm from the divided short gastric artery on the posterior fundus. Penrose was placed around the esophagus between the posterior vagus and the esophagus. We held the Penrose and stabilized this area, brought the marking suture around the esophagus, and performed the shoeshine maneuver. We then placed sutures from the right fundus to the upper portion of the right crus. Left-sided fundus to the upper portion of the left crus, followed by three sutures from the fundus to the esophagus on both sides (Figure 3D). We checked the EndoFLIP values to ensure that fundoplication was not too tight.

Closure

Typically, the entire operation takes approximately 2 h, with an estimated blood loss of 30 cc. After ensuring good hemostasis, the sutures, Surgicel, and Penrose drain were removed along with the resected hiatal hernia sac. Next, the liver retractor and robotic instruments were removed. Finally, the ports were removed, ensuring hemostasis at the port sites. The skin was closed with absorbable sutures.

Postoperative considerations and tasks

After the surgery, the patient was kept overnight in the hospital to ensure that they could tolerate a liquid diet and that their pain was manageable with oral pain medication. The patient started on a clear liquid diet after the operation and advanced to a full liquid diet the next morning. Most patients experience shoulder pain due to abdominal insufflation. Patients were started on multimodal non-opioid medications, including acetaminophen, gabapentin, methocarbamol, and naproxen (7). Most patients go home without opioid medication and stay on acetaminophen for 5 days after surgery. Patients stayed on a full liquid diet for 2 weeks; if they did not have any issues with liquid diet, they advanced to a soft diet for 1 week followed by 1 week of regular diet except for steak, bread, and rice. Finally, 5 weeks after surgery, the patients were placed on a regular diet without restrictions. The patients were placed on scheduled simethicone for 1 month to prevent significant bloating. The medication was continued as needed after 1 month.

Tip and pearls

The key to the dissection of the hiatal hernia is pulling only on the hernia sac during mediastinal dissection. Pulling the stomach down into the abdomen during the dissection of the hiatal hernia is avoided since the stomach will just go back into the thoracic cavity after release or it will lead to serosa tear. Once the hernial sac is fully mobilized, the stomach can be reduced into the stomach, and it will remain below the diaphragm.

Discussion

Full dissection of the esophagus above the gastroesophageal junction, with mobilization of both the anterior and posterior vagus away from the esophagus, releases the esophagus and leads to lengthening of the esophagus. This circumvents the need for Collis gastroplasty.

Conclusions

Resection of the fibrotic tissue around the esophagus above the gastroesophageal junction should be used to provide adequate intra-abdominal esophageal length during giant hiatal hernia repair.

Acknowledgments

The author would like to thank Rachael Whitehead at Houston Methodist Hospital for the illustrations.

Funding: None.

Footnote

Reporting Checklist: The author has completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-41/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-41/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-41/coif). M.P.K. has not received any funding for this work. In the past 36 months, he had received honoraria for teaching other surgeons in using technology for Intuitive Surgical and Medtronics. He consulted Olympus and received royalties from Medtronics for an educational video. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and the Helsinki Declaration (revised in 2013). Written informed consent was obtained from the patient for the use of video and patient information for educational purposes. A copy of the written consent is available for review by the editorial office of the journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Landreneau RJ, Del Pino M, Santos R. Management of paraesophageal hernias. Surg Clin North Am 2005;85:411-32. [Crossref] [PubMed]
2. Mitiek MO, Andrade RS. Giant hiatal hernia. Ann Thorac Surg 2010;89:S2168-73. [Crossref] [PubMed]
3. Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg 1967;53:33-54. [Crossref] [PubMed]
4. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery. Ann Surg 2000;232:630-40. [Crossref] [PubMed]
5. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg 1996;171:477-81. [Crossref] [PubMed]
6. Shah A, Kim MP. Gastroesophageal Reflux Disease in 2023: When to Operate and Current Endoscopic Options for Antireflux Therapy. Thorac Surg Clin 2023;33:125-34. [Crossref] [PubMed]
7. Kim MP, Godoy C, Nguyen DT, et al. Preemptive pain-management program is associated with reduction of opioid prescriptions after benign minimally invasive foregut surgery. J Thorac Cardiovasc Surg 2020;159:734-744.e4. [Crossref] [PubMed]
8. Nwokedi U, Nguyen DT, Meisenbach LM, et al. Short-term outcome of routine use of EndoFLIP during hiatal hernia repair. Surg Endosc 2021;35:3840-9. [Crossref] [PubMed]